1. The staff members in a local Emergency Department are experiencing stress and burnout as the result of excessive overtime. The staff decides to unionize to negotiate for better working conditions. The increase in unionization within health care may be attributed to the:
a. Movement from being blue-collar workers to being knowledge workers.
b. Excess profits in health care.
c. Level of risk that exists for health care.
d. Number of people who are involved in health care.
ANS: D
As technology replaces unskilled workers, fewer workers are available for trade-union organizing, which has led to declines in union memberships. Nurses represent a large pool of workers who may be available for union organizing in the face of the declining pool available elsewhere.

REF: Page 355 TOP: AONE competency: Business Skills

2. The Emergency Department nurses decision to organize for the purpose of collective bargaining is being driven by a desire to:
a. Establish the staffing pattern that will be used.
b. Determine the hours that one is willing to work.
c. Create a professional practice environment.
d. Protect against arbitrary discipline and termination.
ANS: C
Historically, nurses were reluctant to unionize. However, concern with safety of care and quality of care, especially when tension is present in a work environment, makes unionization more desirable. U.S. Supreme Court rulings have provided for RN-only units and protection to practice according to what the profession and licensure status require nurses to do.

REF: Page 356 TOP: AONE competency: Business Skills

3. The Emergency Department staff decides to use a collective bargaining model for negotiation rather than a traditional trade union model. A traditional trade union model is characterized by:
a. Positional conflict.
b. Management support of labors initiatives.
c. A spirit of trust between management and labor.
d. An ability to resolve complaints.
ANS: A
Collective bargaining encompasses management support of labors initiative, a spirit of trust between labor and management, and resolution of problems. It replaces the positional conflict that has been associated with traditional trade unions. Models such as the interest-based problem solving (IBPS) model seek to avoid positional conflicts such as those between labor and management that do not take into account the opposing party in any way.

REF: Page 354 | Page 357 TOP: AONE competency: Business Skills

4. The chief nursing officer utilizes the hospitals workplace advocacy to help the overwhelmed Emergency Department staff. Workplace Advocacy is designed to assist nurses by:
a. Creating professional practice climates in their institutions.
b. Equipping them to practice in a rapidly changing environment.
c. Negotiating employment contracts.
d. Representing them in labor-management disputes.
ANS: B
Workplace advocacy encompasses a number of activities that enable nurses to control the practice of nursing and to address challenges that they face in the practice setting. These activities include career development, employment rights, employment opportunities, and the labor-management relationship. The aim of workplace advocacy is to proactively equip nurses to practice within a rapidly changing environment, rather than to negotiate contracts or provide representation in employment disputes.

REF: Page 352 TOP: AONE competency: Business Skills

5. Nursing labor management partnerships:
a. Engage nurses at all levels in problem solving for better patient care.
b. Require unions and management to negotiate in good faith regarding hours of work and wages.
c. Have been shown to have negligible effects on nurse turnover and patient outcomes.
d. Have typically resulted in increased polarization of nurses and management, leading to formation of collective bargaining units.
ANS: A
The development of a nursing labor management partnership is an approach that can be used in most professional nursing environments. This process recognizes nurses as leaders on all levels and provides formal and informal mechanisms for professional nurses to work together to achieve shared goals through collaboration and shared decision making or decentralized decision making. A study of a nursing labor management partnership suggested that nurse satisfaction was higher, turnover was lower, and more time was available for patient care.

REF: Page 355 TOP: AONE competency: Business Skills

6. A Magnet hospital surveys the staff about job satisfaction. This type of environment, in which nurses have authority and autonomy, is linked with:
a. Client satisfaction with the healthcare organization.
b. Organizations with a limited number of nurse managers.
c. Private, specialty organizations in urban areas.
d. Sophisticated academic health sciences universities.
ANS: A
Autonomy and authority in decision making that is consistent with scope of practice are linked both to higher job satisfaction and to higher patient satisfaction with care. Job satisfaction is an important indicator of the quality of patient care.

REF: Page 350 TOP: AONE competency: Business Skills

7. In a nurse managers meeting, strategies for ways to help retain staff are discussed. One strategy for assisting nurses in developing collective action skills is:
a. Accepting the practice of going along to get along.
b. Attending as many workshops as practical.
c. Spending as much time as possible in clinical settings.
d. Taking the opportunity to work with a mentor.
ANS: D
Mentoring facilitates development and adoption of positive interaction and other skills that facilitate good decision making. Optimism, trust, and decision making are important in collective action and shared decision making and contribute to job satisfaction and lower turnover in staff.

REF: Page 351 | Page 353 TOP: AONE competency: Business Skills

8. While making rounds, a night supervisor finds a unit with a low census and too many staff members. The night supervisor is performing as a statutory supervisor when he or she:
a. Assigns nurses to care for specific clients.
b. Develops a protocol for unlicensed personnel.
c. Recommends transferring a nurse to another service.
d. Teaches a nurse to use a new piece of equipment.
ANS: C
The night supervisor is acting in accordance with the National Labor Relations Act, which would enable the supervisor to assign nurses to care.

REF: Page 349 TOP: AONE competency: Business Skills

9. The Emergency Department staff members are concerned that working long hours without rest puts patient safety at risk. One staff member decides that she will risk her job and become a whistleblower. Whistle-blowing is an appropriate recourse when management:
a. Disregards due process when disciplining a nurse.
b. Delays responding to repeated efforts to provide safe care.
c. Hires nurses who are not a part of the union during a strike.
d. Refuses to bargain in good faith with the elected bargaining agent.
ANS: B
Whistle-blowing is often a result of organizational failure, including failure of the organization to respond to serious danger or wrongdoing created within the environment, which, in this instance, involves conditions that put the patient at risk.

REF: Page 349 TOP: AONE competency: Business Skills

10. As a new nurse manager who has inherited a unit with high nurse turnover and complaints of patient dissatisfaction, your first course of action would be to:
a. Determine levels of nurse engagement on the unit.
b. Review the personnel files of nurses who have resigned.
c. Interview upper management about their vision for the unit.
d. Meet with your staff to clarify your vision for the unit.
ANS: A
Multiple studies demonstrate that a healthcare organization that provides a climate in which nurses have authority and autonomy has better patient outcomes, retains nurses at a higher rate, is more cost-effective, and has evidence of greater patient satisfaction than an organization in which such a climate does not exist (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Dunton, Gajewski, Klaus, & Pierson, 2007). Organizational assessment assists in identifying the reasons for high nurse turnover and patient complaints.

11. In an inner-city area, a group of nurses meet and develop a plan to negotiate with local businesses to support a breakfast program for young elementary schoolchildren. This is an example of:
a. Community development.
b. Collective bargaining.
c. Collective action.
d. Shared governance.
ANS: C
Collective action refers to activities undertaken by a group of people with common interests and, in this example, by a group of nurses who are interested in the welfare of children in their community.

12. In accomplishing the goal of breakfast for children in elementary school, Leanne is particularly effective in approaching businesses with the needs that the group has determined and articulating the ways that the group has found for businesses to participate. Leanne is exemplifying:
a. Leadership.
b. Followership.
c. Professionalism.
d. Knowledge of context.
ANS: B
Effective followership involves active and loyal involvement in an agenda that has been established. In this role, Leanne is supporting and operationalizing the agenda and strategies that have been established within the group.

13. Awareness and use of power have been challenging for nurses in general because of:
a. Incidences of punishment by authority figures.
b. Too little time in the workplace to collectively develop power strategies.
c. Lack of cohesiveness and unity among nurses.
d. A tradition of obedience to authority.
ANS: D
Rituals and traditions such as the Nightingale Pledge have emphasized the need for the good nurse to be obedient to authority. This prevailing attitude has made it difficult for nurses, who typically spend considerable time in the workplace and who have opportunity through their work in teams to develop cohesiveness and unity, to develop awareness and use of power.

14. Collective action is effective in:
a. Ensuring that needs of nurses are placed ahead of other disciplines.
b. Defining nursing as a profession.
c. Advising patients of the needs of nurses.
d. Amplifying the influence of individuals.
ANS: D
Individuals may have limited influence in achieving various purposes such as advancement of quality care or of the profession, whereas collective action helps to define and sustain individuals in achieving the desired purposes.

REF: Page 348 TOP: AONE competency: Business Skills

15. Nurses on the dialysis unit notice that changes in labeling of fluids have meant several alarming near misses in terms of wrong administration of fluids. They take this concern to the unit manager. As an advocate of nurse autonomy, the most appropriate response in this situation would be to:
a. Ensure that the nurses are aware of the reasons for the change and how the decision was made about the new labels.
b. Discuss concerns about the labels and develop potential solutions that take into account changes that can be made at the local level and those that need system intervention.
c. Suggest that the staff wait until they have become more familiar with the labels before taking further action.
d. Tell the staff that you will notify the pharmacy about these concerns and leave it up to the pharmacy to decide what should be done.
ANS: B
Participation in decision making regarding ones practice is an appropriate expectation for professional nurses, provides for greater autonomy and authority over practice decisions, contributes to supporting the professional nurse, and is a major component of job satisfaction (Kramer et al., 2008; Pittman, 2007). Autonomy is encouraged through supportive management and through unit-level support of changes without the need for complex, multilevel approval of changes that can be made locally.

REF: Page 348 | Page 349 TOP: AONE competency: Leadership

16. Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Martins follow-up to complaints from the community is:
a. Appropriate and indicates that he has assumed accountability for the actions of his staff.
b. Indicative that he does not clearly understand the concept of accountability.
c. Indicative of strong support for his staff and their autonomy.
d. Important in clarifying the difference between his accountability and that of the community in patient care.
ANS: B
Accountability refers to the achievement of desired outcomes. If community agencies are noticing that limited or no change in patient behavior has occurred despite teaching on the unit, then the staff has not achieved accountability, and he is not holding his unit responsible for the outcomes. Martin is also demonstrating lack of accountability.

REF: Page 350 TOP: AONE competency: Professionalism

17. Sarah determines, in partnership with her patient, that current medications are not enabling her patient, a married account executive with fibromyalgia, to continue with her employment and family responsibilities. After searching for additional information on fibromyalgia, Sarah finds nonpharmacologic interventions that are supported through credible evidence. Sarah suggests that the patient, her physician, and she meet to discuss the medications and possible options and a plan of care for the patients discharge. This action exemplifies which of the four historical concepts identified by Lewis and Batey?
a. Authority
b. Responsibility
c. Communication of conflict
d. Autonomy
ANS: A
Authority refers to the use of professional status and power to act in the patients best interests. In this example, Sarah is using her professional status and power to set up a conference in which her patient, the prescribing physician, and she can discuss what is not working for the patient and potential options.

REF: Page 349 TOP: AONE competency: Professionalism

18. In looking at an organizational chart for her institution, Jennifer notes that nursing is led at the senior level by a non-nurse executive. Jennifer expresses concern that this is a reflection of how nursing is viewed within the organization. Jennifers comments reflect:
a. A concern that resource allocation will be made on a business and not a professional model.
b. The dissatisfaction that occurs when lack of autonomy is given to nurses.
c. Concern with the nonadvancement of nursing practice in the institution.
d. An awareness of how organizational culture is reflected in organizational structure.
ANS: D
The organizational chart reflects the formal structure of the organization and can reflect predominant beliefs, values, and relationships in the organization. Exclusion at senior executive levels of nurse leaders may reflect institutional beliefs about how resources are allocated, the degree of autonomy given to staff, and involvement of key groups in decision making.

19. Government and third-party payers announce reduction of compensation for the delivery of patient services. Hospital STV has a flat organizational structure. After the funding announcements, senior officials at the hospital meet and make decisions regarding cost containment of new revenue streams. This action is consistent with:
a. The practice of leaving financial decisions with senior officials who understand the total context of funding.
b. A tendency to concentrate decision making during economic downturns at the top administrative level.
c. A need to make expedient decisions that are likely to be poorly received by staff.
d. Ensuring that decisions with regard to cost are made equitably across all departments.
ANS: B
During times of economic downturn, decisions tend to become very centralized to avoid risk. History demonstrates that increasing the breadth of input during these times is more effective than narrowing it.

20. In Hospital STV, senior administration is strongly oriented toward fiscal and social conservatism. The nursing department is deeply concerned with the provision of quality to the community, which includes a high number of poor and unemployed. To accomplish the goals of the nursing department, resources need to be allocated that administration is not able to allocate. Nursing and administration:
a. Are engaged in shared governance.
b. Are involved in an irreconcilable conflict of interests.
c. Represent separate subcultures in the institution.
d. Represent union and nonunion conflict.
ANS: C
Institutions can have several subcultures, which are represented by unique features and distinct ideologies. Subcultures can be congruent and can support healthy relationships in the organization, or they may be separated and characterized by tensions that may be irreconcilable and destructive. From the information given in this scenario, it is not evident that shared governance, union presence, or irreconcilable differences are present.

21. On Unit 62, the nurses and the unit manager have been involved in shared decision making related to the model of nursing care delivery that the unit will adopt. All individuals have participated and been involved in decision making and implementation of changes. When issues arise during implementation, it is expected that:
a. Accountability resides entirely with the unit manager.
b. Individual expertise will be utilized to provide solutions, but that responsibility for the change is shared.
c. No one really has any accountability or responsibility for the changes.
d. This will contribute to widespread skepticism among the staff about the probability of success.
ANS: B
High-performing organizations provide for participation by all stakeholders, and each stakeholder shares responsibility and risk. This kind of environment is more satisfying for nurses and is characterized by optimism and trust.

22. Senior executives at Hospital A determine that the hospital will engage in a strategic planning process after changes in healthcare funding and concerns expressed in the community about care that is being delivered at the hospital. The senior executives decide on a participatory process in which staff are widely consulted regarding input about the organization and the external environment and are actively invited to be part of decisions related to the mission statement, goals, and objectives. For true shared governance to be seen as part of this approach:
a. It must be evident in the outcomes of the process that staff and senior executives have partnered on the decisions.
b. Stakeholders must be assured of the value of their input even though final decisions rest with senior executives.
c. Publications must clearly outline how staff input was solicited and obtained.
d. Staff must be reassured that significant concerns will be kept in mind even if they have not been addressed in planning documents.
ANS: A
Shared governance demands participation in decision making. When partnership, equity, and ownership are not involved, then shared governance has not occurred, and publication and expressions of appreciation for input will not be seen as representative of shared governance.

23. Nurses in an Emergency Department, in an inner-city neighborhood characterized by high levels of violence, are concerned with low levels of security presence in their department. Security levels have recently been decreased and the nurses question why this has occurred. An appropriate action would be to:
a. Provide nurses with information about rationale for recent changes in security staffing.
b. Refer the matter to the head of security and let her deal with it.
c. Provide mentors who can help nurses diffuse aggressiveness.
d. Accept the security levels as a consequence of funding realities.
ANS: A
Workplace advocacy is an umbrella term encompassing activities within the practice setting. Workplace advocacy includes an array of activities undertaken to address the challenges faced by nurses in their practice settings. The focus of these activities is on career development, employment opportunities, terms and conditions of employment, employment rights and protections, control of practice, labor-management relations, occupational health and safety, and employee assistance. The objective of workplace advocacy is to equip nurses to practice in a rapidly changing environment. One manifestation of workplace advocacy is ensuring that relevant information is shared about decisions that affect practice so that further data gathering and decision making (in this instance about security levels and nurse safety) is informed.

24. You are hired as a new manager. When the offer of employment is made, you agree to at-will employment. Later, you become very concerned about the policies and practices of your organization and their impact on patient care. You speak with your supervisor several times about your concerns, but no action is taken. In considering your next steps, you:
a. Consider your increased vulnerability under the terms of your employment.
b. Recognize that your supervisor is more vulnerable than you are because of her more senior position.
c. Are more likely as a leader to take action because you are well protected from repercussions by federal and state regulations.
d. Contact your union to discuss your concerns and review your options.
ANS: A
Managers of at-will employees have greater latitude in selecting disciplinary measures for specific infractions. State and federal laws do provide a level of protection; however, an at-will employee may be terminated at any time for any reason except discrimination. At-will employees, in essence, work at the will of the employer. Nurses in these positions need to know their rights and accountability.

REF: Page 356 TOP: AONE competency: Business Skills

25. Sandra, an RN on the surgery unit, is assisting with a procedure in the patient examination room. The physician orders a medication to be given through IV. Sandra questions the order, based on her knowledge of the patients history and of other medications that the patient has been given. The physician reiterates the order and Sandra refuses to give it. In this instance, Sandra is demonstrating:
a. Autonomy.
b. Accountability.
c. Authority.
d. Best practice.
ANS: A
In this situation, Sandra is exemplifying autonomy, which is the act of making independent decisions in the best interests of the patient, based on her knowledge and experience. This is analogous to the example in the text where the workers on the manufacturing floor have the independence to say Stop the line when something is wrong. Key to the concept of autonomy is decision making and the level of independence that is given. Accountability refers to achievement of outcomes, and authority refers to the capacity to make decisions.

1. Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Potential outcomes of Martins actions include (select all that apply):
a. Poor morale on the unit.
b. Disruption in community relationships.
c. Corruption of patient-staff relationships.
d. Patient outcomes for quality care are met.
ANS: A, B, C
Kupperschmidt (2004) points out that when accountability is not accepted, then relationships suffer, professional practice is diminished, and self-esteem suffers.